American Journal of ORTHODONTICS
and DENTOFACIAL ORTHOPEDICS
Founded in 1915
Copyright 9 1992 by the American Association of Orthodontists
Considerations of dentofacial growth in long-term
retention and stability: Is active retention needed?
Ram S. Nanda, DDS, MS, PhD," and Surender K. Nanda, DDS, MS b
Oklahoma City, Okla., and Ann Arbor, Mich.
T h e question of long-term retention and sta-
bility of occlusions after orthodontic treatment has al-
ways engaged the attention of the specialty. The im-
provements achieved from long and painstaking treat-
ment may be lost to varying degrees after the appliances
are removed. Sometimes relapse in tooth positions is
noted even during the period when a patient is using
the retention appliances. The question often asked by
patients and orthodontists is how long should active
retention with appliances be maintained?
Recent studies v3 on the assessment of long-term
observations of posttreatment results have indicated that
relapse occurs in most cases. Orthodontic treatment
rendered in conjunction with extraction or nonextrac-
tion procedures met the same fate. No variable was
found to be predictive of either stability or relapse.'*
Does contemporary orthodontics have no satisfactory
solution to the problem of achieving long-term stability?
A central question in the famous extraction/nonex-
traction debates of Case and Angle was the stability of
orthodontic treatment. Case challenged Angle's phi-
losophy that nature always starts out to build a perfect
denture in each person and that malocclusions were
caused by local factors. On the other hand, Case pro-
moted the theory of biologic variation and inheritance
in the development of malocclusions. Case pleaded for
extractions of first premolars in the treatment of patients
with certain types of Angle Class II, Division I and
bimaxillary protrusion malocclusions. Case stated, in
*Professorand chairman, Departmentof Orthodontics, Universityof Oklahoma
College of Dentistry.
bProfessor, Departmentof Orthodonticsand Pediatric Dentistry,The University
of Michigan Dental School.
811123852
Volume 101 Number 4 April 1992
ORIGINAL ARTICLES
reply to his critics, that "upon no basis but the Bible
theory o f special creation can I reconcile the teaching
that nature puts teeth into an individual's mouth that
donot belong to his or her physiognomy.''5
The debate on extraction versus nonextraetion
_orthodontic treatment approaches has waxed and waned
throughout this century. The matter of long-term sta-
bility of the corrected result has never been satisfactorily
resolved. Perhaps several additional factors may have
an important bearing on orthodontic stability. Among
them are the influence of growth changes in dentofacial
structures, balanced occlusion, and harmonious oro-
facial musculature. The intent of this article is to focus
on the effect of growth changes of the dentofacial struc-
tures on retention and stability of treated dentitions.
DENTOFACIAL SKELETAL CHANGES
WITH GROWTH
Relapse of the corrected position of the teeth after
successful orthodontic treatment is fully recognized by
the clinician. However, skeletal changes that occur dur-
ing retention may attenuate, exaggerate, or maintain
the dentoskeletal relationship. Relapse of the teeth is a
source of annoyance to all concerned; yet the outcome
of skeletal changes is left to the fate of the patient's so
called "growth pattern." Despite the fact that the clinical
manifestations of skeletal relationships are given con-
siderable importance before the initiation of and during
orthodontic treatment, little or no consideration is given
to posttreatment skeletal changes due to growth and
their effect on the final outcome. This attitude is prob-
ably based on two assumptions. First, it is often as-
surned that the responsibility for skeletal supervision is
secondary to the dental relationships during active treat-
ment. Further, when teeth are brought into proper in-
297
298 Nanda and Nanda
I I I I I I
O'Deep-
1 is completed. Failure to recognize the dominant mor-
O'qOpen- 453
2
~ Deep - I 35
Open - 1 32 5 4
I I ! I ! !
11 12 13 14
YEARS
Fig. 1. Schematic representation showing the timing of the peak
of the pubertal spurts for five facial dimensions in subjects with
open bite and deep bite. (From Nanda SK. Patterns of vertical
growth in the face. AM J ORTHODDENTOFACORTHOP 1988;
93:103-'16.)
terdigit'ation, the treatment is usually terminated, re-
gardless of the skeletal maturation status of the patient.
Second, it is generally assumed that not much can be
done during the posttreatment phase to modify the
growth pattern of the patient. The truth of the matter
is that many patients at the completion of orthodontic
treatment may still be going through the pubertal growth
spurt, and there may be others who have not even en-
tered the period of accelerated pubertal growth. This
observation is of particularly greater significance in
boys than in girls, since boys generally mature later.
Hence, failure to recognize the continuing effect of
dentofacial growth after the completion of orthodontic
treatment and its resultant favorable or unfavorable ef-
fects on the physiognomy and its dental relationships
may jeopardize long-term stability of the orthodontic
result.
Alternatively, the convenient assumption is often
made by the clinician at the completion of treatment
that future skeletal growth is of no consequence or that
dentofacial changes will be proportional and thus will
maintain the skeletal relationships that were established
during treatment. Therefore the major focus during re-
tention is placed on maintenance of the corrected po-
sitions of the teeth, and no compensations are made for
the future dentoalveolar and skeletal growth of the jaws
in either the horizontal or the vertical direction.
What is suggested here is that the retention devices
should be differentially selected on the basis of den-
tofacial morphology and the anticipated magnitude and
directions of growth instead of simply using the clini-
cian's favorite procrustean-bed retention appliance for
all cases.
Specifically, the effect of continued growth after
successful treatment is critical in persons with short-
Am. J. Orthod. Dentofac. Orthop.
April 1992
! I | ] face syndromeY These persons may require dentoal-
31 524 veolar compensations, such as an anterior biteplate dur-
ing the retention phase until maxillomandibular growth
phogenetic horizontal pattern of growth of the person
may result in a "dished-in-face," with or without ex-
tractions of teeth. Imagine the effect of the additional
soft tissue growth, particularly in the nose of the patient
with a deep bite and a short, vertical facial height. Such
t I i
15 16 changes only accentuate the concave facial pattern.
Conversely, how about those persons who are char-
acterized by long-face syndrome? They may require a
high-pull face-bow headgear to hold the position of
molars and to prevent further dentolaveolar growth
downward and backward, autorotation, and worsening
of the physiognomy. To oux~chagrin, in some cases even
the dental relationships of the teeth deteriorate, with a
noticeable relapse of dental open bite due to the lack
of ramal growth or excessive vertical dentoalveolar
growth.
Of particular clinical significance is the timing of
the pubertal growth spurt in persons who manifest se-
vere skeletal dysplasia (Fig. 1). Too often the clinician
assumes that the timing of the pubertal growth spurt
between patients with open bite and those with deep
bite within each sex is the same as that usually rec-
ognized between males and females. However, the pu-
bertal gr0wih spurt in patients with skeletal deep bite
within each sex is shifted 1 J/z to 2 years later than in
the patients with open bite. This is true even when the
effect of sexual dimorphism is recognized because girls
grow earlier and complete their growth before boys.
These patients require a longer retention period than
the skeletal open-bite subjects d o . 7
Again, it is recognized that the mandible can con-
tinue to grow until the late teen years. However, this
may not happen in all persons. It is often observed
clinically that in severe Class II cases in which the
maxilla is protrusive (large anteroposteriorly), it con-
tinues to grow longer, while the mandible may be ex-
periencing little or no growth. This may alter the spatial
relationships of the dental arches. In this situation, it
may be appropriate to maintain the anteroposterior po-
sition of the maxilla with a high-pull face-bow head-
gear. 8 This retention device will prevent dentoalveolar
growth of the maxillary molars and may in some in-
stances improve the facial configuration. Differential
posttreatment diagnosis is thus as important as pretreat-
ment growth projections.
The point to be made is that the clinician has to be
alert to the growth pattern of an individual patient.
Routine use of average values as a standard against
which to measure deviations in size and maturational
Volume 101 Dentofacial growth in long-term retention and stability 299
Number 4

PERCENTAGE INCREMENT PER 6 MONTHS

~,, *.,i J ! 1 f I [ i
/ '
m ,~ i ! * J'
Ep ; I " r ~ I, , i
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-< ~ i : II 9 I , ! , IIIII I
IIIII r -
I II1~II
Ilqlll i :
IV,I l l
IMIII
liUli

PERCENTAGE INCREMENT PER 6 MONTHS

!1 . J : II f
t I 1 i r f i I I I
), ,, I l I r k i , I I r l
I11
i | | IJ r [ ! I I i il li ,'
I r V I i I l i 11 II I I
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i - ~ I I I I I I 1% I I' ! ',
t I 1 I ~ I i ! tl I L i T 9
-- I i ~ I% t| ~i ~ I-qi - r
l ~ 1 :- 4h~ 7" q, ill I r i i
. ' i. i-i jr II i" , ; i i i I# Ij "
/ i" 1 ~ ,'t I / i il I II 'f
;~ ~ r lit L41: ~ E ~- i ' r f-~ - i t - , - '
~} i I .I ~ iI 1 li ~ / i , ) ! iI , iI i ~ )
Z

Fig. 2. Comparison of dimensions of sella-gnathion and nasion-gnathion in 10 subjects. Early-and-late

maturing subjects are chronologically arranged showing tremendous variation in the timing of pubertal
maximum. Arrows indicate the timing of pubertal maximum peak growth for each individual measure-
ment. Also note that the pubertal m a x i m u m for each measurement occurs at different times, and in
the chronologic order of sequence the position of a person may vary. Nanda also reported similar
observations on other facial dimensions. No single person follows the peaks and valleys of the median
incremental growth curve. The resultant median curve (bottom of each figure) shows a centr~il trend.
(From Nanda RS. The rates of growth of several facial components measured from serial cephalometric
roentgenograms. AM J OarHOD 1955;41:658~

status of various dentofacial parameters for orthodontic impact of peaks and valleys has been diminished by
diagnosis and treatment planning has lulled too many the method of averaging (Fig. 2).
clinicians into thinking that the patient will or is ex- Thus the biologic variations in a patient population
pected to follow an average pattern. Too many treat- are so large and exceedingly difficult to predict that the
ment plans are developed with mean numbers assigned clinician capitulates as the growth pattern deviates from
to a group of cephalometric measurements. However, the "averages" available from various cephalometric
longitudinal growth studies have always emphasized the studies. 9~3 It is our belief that the "longitudinal studies"
importance of the variations between persons as well have too often dealt with the data on a cross-sectional
as the various parameters within the same person. basis in developing the "normal" or average values.
Fig. 2 shows a comparison of the dimensions of sella- They have presented the clinician with a far too sim-
gnathion and nasion-gnathion in 10 subjects. Early- and plistic "numbers racket" approach to a very complex
late-maturing subjects are chronologically arranged, phenomenon. Despite computer sophistication, precise
showing tremendous variation. No one person follows prediction of the facial growth pattern in its various
the peaks and valleys of the median curve. Peaks and dimensions still eludes our present knowledge. It is of
valleys of persons will tend to average out the fluctua- "urgent importance to recognize this fact rather than to
tions. The resultant average curve provides us with a conveniently ignore it.
central trend but represents no single person, and the That the duration and magnitude of the circumpu-
300 Nanda and Nanda Am. J. Orthod. Denwfac. Orthop.
April 1992

14 NASION-GNATHION . 4 8

13]

111 1
5

z
" 81,

13
! I !

SELLA-G~TNION~
! I t I
1
12 -

, , , , , ,
8 4 6 8 1 0 1 2 1 4 1 6 1 8 2 0 5 4 6 8 1 0 1 2 1 4 1 6 1 8 2 0
AGE IN YEARS
CRC BOY, NO. 32
CRC BOY, NO. 83

Fig. 3. Comparisons of absolute dimensions of two men in a group of ten. (From Nanda RS. The rates
of growth of several facial components measured from serial cephalometric roentgenograms. AM J
OlaTHOO 1955;41:658-73.)

bertal growth vary with the person and even within the
same person is abundantly clear. The age at which each
person--and, for that matter, each particular facial
dimension--reaches the adult size depends on his or
her own pattern of physical growth and maturation.
Take, for example, the longitudinal facial growth rec-
ords of two men shown in Fig. 3. Five linear cepha-
lometric measurements of their faces have been color
coded and highlighted in a group of 10 cases. You will
note that the man in case No. 32 had a relatively small
facial length at the age of 4 years. Even at age 19 years,
his size has remained rather small relative to the group,
and his rank is consistent with respect to the other
nine persons. On the other hand, in case No. 83 sella-
gnathion and nasion~ are relatively large, but
sella-nasion and gonion-gnathion are small. Sella-
gonion is the largest and gonion-gnathion is the smallest
in the group, thus giving this subject a long face that
is proportionately small in depth. Also note that sella-
gonion is still growing at the age of 20.
If we superimpose the relative incremental curves_
on the same age scale for their different measurements,
as in Fig. 4, it is apparent that each dimension has a
different rate of growth. In the case of subject No. 32,
gonion-gnathion grew at a relatively greater rate be-
tween the ages of 5 and 9 years, but during adolescence
sella-gonion picked up the momentum and continued
to exhibit more growth. In contrast the man in case No.
83 shows greater circumpubertal growth in gonion-
gnathion than all the other measurements and the onset
and maxinzum of puberal spurt in this dimension was
later than all the rest. However, between the ages of
17 and 18 years this person experienced larger and
continuing growth in sella-gonion. Surely, we cannot
retain the results of orthodontic treatment with the same
appliances in these two patients!
Many of these changes may continue even into the
20s for some persons. Growth studies by Nanda, 14-~6
Nanda et al. t7 and Behrents '8 have shown that, in males
particularly, growth in facial skeleton and soft tissues
continues past the age of 18 years. Even a change of
1 to 2 mm during the postpubertal years may have a
profound effect on the long-term stability of an ortho-
dontic treatment result.
Volume I01 Dentofacial growth i~z long-term retention and stability 301
Number 4

~ oo p,
(n YRS "10 YRS 15 YRS 20 YRS
p. 3 1 i i i i i i i i ! i m | m I

z
o No. 32
~0
rr 2
UJ
el
Ul

Ul
IE
I

z_ I !
04" 6 8 10 12 14 16 18 20
SE/~ NA S E / ~ NA SE/~ NA SE~ NA

;YRS 10YRS GN 9 . . 20YRS GN

3 i | i i ! | i i i i .i i " I 0 " |
Z
o No. 83
r
ee
tll
el
(n
i..
z
uJ 1
uJ
rr

z_
! t f

0 4 6 8 10 12 14 16 18 20

AGE IN YEARS
~ - SE-GO~ SE-GN .NA-GN~--!GO-GN ----'SE-NA-
Fig. 4. Comparison of percentage increments in two men, three-point smoothed twice. (From Nanda
RS. The rates of growth of several facial components measured from serial cephalometric roentgen-
ograms. AM J ORTHOD1955;41:658-73.)

SUMMARY nicians who advocate permanent retention guidance.

It is extremely important to pay attention to the
person's growth pattern, and a distinction must be made
in the selection of retention devices on the basis of the
nature and the extent of dentofacial dysplasia (growth
pattern). The nature and duration of retention should
depend on the maturation status of the patient and on
anticipated future growth. Retention guidance is nec-
essary for adjustment of the dentition to late growth
changes and maturation of neuromuscular balance.
"Active retention" is a concept we accept as readily as
the orthopedic surgeon does for his scoliosis patients.
There is some merit in the philosophy of those cli-
Without always being aware of the biomechanics of
growth change, they are in fact carrying the patient
through the active stages of growth with their retention
appliances.
Finally, one may philosophize that nothing about
the human morphology is stationary. Aging is a well-
documented process of change? s Lifetime dentitional
adjustment and changing dental relationships are known
to all, even in otherwise healthy persons. Then why do
we expect long-term stability in every case? The answer
to the question of long-term stability is long-term
retention--dynamic, not static.
302 Nanda and Nanda
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2. Little RM, Riedel RA, /~rtun J. An evaluation of changes in
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I .
plasla. Angle Orthod 1990;59:113-22.
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12. Steiner CC. Cephalometrics in clinical practice. Angle Orthod
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Reprint requests to:
Dr..Ram S. Nanda
Department of Orthodontics
College of Dentistry
University of Oklahoma
P.O. Box 26901
1001 Stanten L. Young Blvd.
Oklahoma City, OK 73190